NHS told to slow down referrals amid rising waiting lists and job cuts

It is only a small increase, 20,000 more added to a waiting list that had fallen for months in a row to 7.4 million: but it’s a warning that the government’s changes are tilting the NHS back in the wrong direction.

The commitment to achieve the 92% target for patients starting treatment within 18 weeks by the end of a five-year parliament had been one of Labour’s few surviving pledges from their manifesto last year, and it now seems set for failure.

And now that failure seems to be guaranteed by new instructions from NHS England to all 42 Integrated Care Boards to slow down any expansion of elective care services. A letter to ICBs points to referrals being too high and aims to manage demand, as the financial constraints limit the growth in capacity.

The reason? The new austerity: chancellor Rachel Reeves has prioritised her commitment not to raise taxes above any promise to repair the damage done to the NHS and other public services by a brutal 14 years of austerity under various Tory governments. Getting the NHS back on its feet was always going to be expensive, requiring ministers to face up to the cumulative cost of years of inadequate pay settlements for staff and lack of investment in buildings and equipment.

Instead Wes Streeting has banged on endlessly about his three priorities: the switch from analogue to digital; the switch of resources from hospitals to care in the community; and a focus on prevention rather than treatment.

These have never made any sense politically: relatively few people want to study their own medical records, or know or care where they are in the queue for elective treatment, but many are all too aware of what it’s like in a queue for emergency care and a hospital bed – which has continued to get longer and more miserable.

And while many might welcome more provision of care in the community, this needs investment to expand and create new services – and it needs to run alongside, not replace tackling the waiting list and logjams in A&E departments and corridors.

Most ridiculous of all is the constant mantra about focusing on prevention rather than treatment when resources are the main obstacle to both, and the latest round of cuts to contain NHS spending run alongside continued financial constraints on local government that make it impossible to tackle wider causes (social determinants) of ill health. Indeed government policy, following on from previous governments, is actually deepening poverty and widening inequalities.

So what patients (and, to judge from the local elections and Runcorn by-election) voters see is not a radical Labour government driving positive reforms, but a barrage of bad news on the continued problems.

In many areas there are reports of trusts planning cuts in clinical as well as non-clinical staff. This follows on from the ongoing cull of posts to halve the running costs in England’s 42 Integrated Care Boards (ICBs), and the 50% reduction in NHS England staff demanded by ministers by December. But it will not surprise Lowdown readers to find the government has made no proper impact assessment of driving so many drastic cutbacks so quickly.

A quick Lowdown survey of available news reports (May 20; see table) shows 18 trusts planning to axe over 7,000 posts as part of their effort to save a total of £1 billion or more. But so far we have hard facts from only a small minority of the 251 trusts, and even the figures that have been revealed are not broken down to show details or allow the consequences to be assessed. The situation seems set to get far worse as more plans and job losses are eventually revealed.

ICB staffing cuts are also beginning to emerge. Board papers show South East London ICB plans to cut the ‘system workforce’ establishment by 3.4% (2,011 Whole Time Equivalents), with almost 1,000 of these to be from substantive rather than temporary or agency staff. Inevitably a majority of these jobs will have to be cut at trust level rather than the ICB itself.

Local BBC reports also indicate a further 1,300 jobs at risk in three East Midlands ICBs (Nottinghamshire, Derbyshire and Leicestershire).

The cynical government response, a limp parody of Elon Musk’s claim that sweeping cuts in jobs in the US are aimed at eliminating “waste”, has been to claim that the aim in each case is to “cut bureaucracy to invest even further in the front line”. But while the cuts are real enough – although by no means limited to “bureaucracy” – there is little evidence of any resulting investment. The extra cash which Labour keeps reminding us Reeves gave to the DHSC last autumn has been largely swallowed up by inflation and belated wage increases.

So far from having extra real cash to invest, the King’s Fund in a new report is warning that since 2022/23, NHS spending has fallen slightly in real terms, while cost pressures have risen.”

The report notes that “the first cut of spending plans for 2025/26 showed ‘a very significant financial deficit’ of £6.6 billion for integrated care systems (ICSs) and trusts,” and the budget setting process has been described as “tougher than previous years.”

NHS managers and senior managers themselves are also angered and frustrated by the latest government twist of policy. A recent statement from their union Managers in Partnership (MiP) has opposed the scale and speed of the cuts and changes.

“Our members, including senior leaders, have found out about many plans from leaks to the media. This is wrong: it is chaotic, disrespectful and counterproductive. It has deeply damaged confidence in the national leadership among hard-pressed and hardworking NHS staff.

MiP warns the government that it is running a huge risk:

“Destabilising cuts and change on this scale will weaken management capacity to carry out the government’s health mission, including making the ‘three shifts’, improving productivity and cutting waiting lists; lead to an unwanted re-organisation; damage services to the public; make tens of thousands of NHS workers unemployed, and undermine focus, morale and workload for the staff who remain.”

The full picture is not yet clear. Some ICBs, especially those which meet only quarterly, have yet to publish any planning for this financial year, while others have refrained from revealing any details. Many will be taking decisions behind closed doors in ‘private’ sessions and committees – leaving staff and the public in the dark.

However we do know almost all acute trusts have yet again been forced to set very big savings targets, many, if not all of them this time requiring reductions in staff to comply with NHS England instructions to cut running costs.

Some – such as Barking Havering and Redbridge University Hospitals, which covers Wes Streeting’s constituency – are warning that even large-scale cuts in staffing will not be enough, and that access to services may have to be restricted. BHRUT Chief Executive Matthew Trainer told a board meeting the trust faced “really hard decisions”, including “deliberate decisions to constrain access to services”. He said a cut of £50million was equivalent to 770 full-time jobs: but the trust actually needs to cut £61m, so:

“I think we’ve tried to do the kind of ‘more for less’ for years. This is about less for less in some instances as well.” The trust would have to “restrict access to certain services in a way that we think will cause the least harm as an outcome”.

North West Anglia FT, too which runs Peterborough and Hinchingbrooke Hospitals, has a £73m savings target – more than 10 percent of its expenditure according to a BBC report.It is looking to cut spending on non-elective activity by 6.4%. If other trusts follow suit it would raise huge new doubts over the government’s ambition to cut waiting lists and waiting times.

The recent NHS Providers survey revealed that nearly half of trust leaders (47%) who responded admitted they are already scaling back services to deliver tough financial plans, with a further 43% still considering this option. Amongst services said to be at risk are virtual wards, rehabilitation centres, talking therapies and diabetes services for young people. NHS leaders face “extremely tough choices”.

But it gets worse. Over a third of trust leaders (37%) said their organisation is cutting clinical posts as they try to balance their books, with a further 40% considering cuts. With trusts told to halve corporate cost growth, 86% of trust leaders said their organisation is going to have to cut posts in non-clinical teams – such as HR, finance, estates, digital and communications – potentially risking efforts to deliver services, innovate, and improve productivity.

The NHS Confederation, too, representing commissioners as well as providers, reported six weeks ago:

“Some leaders of NHS trusts have said they are each looking to cut between 200 and 500 roles, while some ICB leaders have said they are likely to remove anywhere between 300 and 400.  […] When looking at the proportion of the workforce that could be removed across NHS trusts, individual estimates from leaders have varied from 3 per cent to over 11 per cent.”

With trusts employing 1.37 million staff, this could mean between 40,000 and 150,000 jobs could be at risk in the quest to balance the books.

But there is a cost involved in axing the jobs: the Confed reports: “Several trust leaders said that they were budgeting for around £12m worth of redundancy payouts and associated costs.” Even if the payouts averaged just £5m across 250 trusts the cost would add up to £1.25 billion this year – but there is so far no government commitment to underwrite this extra cost: if they do not do so the redundancy costs themselves will trigger more cuts in staff and services.

A high risk approach for many ICBs and trusts is to invite senior managers and experienced staff to apply to leave voluntarily with payments of up to £80,000 on the “mutually agreed resignation scheme” (MARS) (for instance Reading’s Royal Berkshire, Liverpool’s Alder Hey and both Kettering and Northampton General). Other trusts, hoping to avoid any pay-offs to staff, are simply freezing vacancies and relying on natural wastage to cut jobs as staff retire or leave for other jobs.

The danger in either case is that the most stressful and vital posts fall vacant – piling even more impossible pressure on the staff who remain, and putting safety and quality standards at risk.

Even if cutbacks in staff could be entirely confined to non-clinical and administrative roles (dismissed by the right wing news media and too many ignorant politicians and members of the public as ‘bureaucrats’ and ‘pen-pushers’) it would be impossible to prevent their departure dumping additional unpaid (and unwanted) tasks and duties on to clinical staff – making it impossible for ministers to deliver their promises of ‘increased efficiency’ and improved performance.

One of the chronic pressure points for performance remains emergency services, where a combination of shortages of beds and a lack of social care and community health services to support patients discharged can result in long delays – and avoidable deaths.

The latest Royal College of Emergency Medicine statistics show that as many as 320 patients per week may have died in England in 2024 as a result of excessive waits for hospital beds in Accident and Emergency departments – a grim 20 percent increase since 2023. Almost half a million patients (478,901) waited more than 24 hours in A&E last year – one in every 35 patients attending, and a 26% increase on 2023.

However improving A&E performance is not among Wes Streeting’s three priorities, or one of Labour’s remaining promises. Instead Streeting wants to shift money out of hospitals and into “neighbourhood” services. But as Streeting’s constituency’s local hospital trust is discovering, the actual situation on the ground is crying out for proper investment after 15 years of austerity.

Queen’s Hospital in Romford and King George Hospital in Ilford had already suffered a £30m cutback in each of the past two years. As more cuts loom, the Romford A&E has just had the busiest winter in its history, with “shameful and difficult” images in the media of its corridors filled with patients. “We are seeing really significant, double-digit increases in attendance,” said CEO Matthew Trainer. “We are lucky we haven’t seen anything worse happen there.”

In the Countess of Chester hospital the reliance on “corridor care” for long-waiting A&E patients has now become so institutionalised that patients stuck on trolleys are handed care packs to help cope with being left on corridors for days at a time, according to LBC.

Each bag contains a letter apologising for the lack of ward space, a bottle of water, an eye mask, ear-plugs to block out the noise, a little toothbrush, a little comb and hygiene products.

If the Streeting plan to further reduce hospital funding continues, and the remaining limited funding is depleted by more use of private providers for elective treatment, it seems certain that corridor care packs will be needed in more and more emergency departments. Without a bold plan for the reform of social care, hospital care will deteriorate for those most needing treatment – with not even a possibility of escaping the delays by going private.

Meanwhile the cutbacks at ICB and NHS England (which faces abolition and “merger” into the Department of Health and Social Care in 2026) mean many senior managers are now inevitably spending little time doing their paid jobs. Instead too many will be calculating their possible pay-offs and pensions if they take redundancy or early retirement – or polishing up their CVs and scanning the job adverts for alternative posts, with the most effective and skilled managers most likely to be offered other work.

Nor is the squeeze limited to revenue spending. The morale of the staff left behind to keep services afloat will not be improved by the visible signs of dereliction and collapse of ageing hospital buildings that should have been repaired or replaced years ago, but now form part of the near £14 billion backlog of maintenance.

In Devon local MPs elected last summer have been taking stock of the state of North Devon and Torbay Hospitals. In North Devon operating theatres date back to 1978 and are now too small and inadequate for modern medical equipment, while Torbay has suffered “almost 700 sewage leaks across the hospital, many impacting on clinical areas,” with only 6% of the hospital meets top-level building standards. Scaffolding to prevent parts of the building falling on to staff and patients is costing £1 million per week.

Former Labour Health Secretary Andy Burnham, now Mayor of Greater Manchester, has urged the government and NHS England to “step back” from their NHS “reorganisation” which “came out of nowhere” and risks “taking people’s focus internally.”

In 2009 Burnham was the only New Labour health secretary to pull back the drive to privatisation of clinical services: he was right then, and his warning is a useful one now.

Streeting’s three priorities distract from any action to tackle the real problem issues on the ground – and as we have seen in the local elections, they are leaving Labour vulnerable in the polls as voters respond to what they feel and see, rather than look up Wes’s latest speech.

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